Coronary CTA appearance of anomalous left coronary artery arising from the pulmonary artery with Intramural Aortic Route

Anomalous left coronary artery from the pulmonary artery (ALCAPA) is a rare anomaly in which the left main coronary artery (LM) typically arises from the left infero-lateral aspect of the main pulmonary artery just above the pulmonary valve. This case report presents a case of variant ALCAPA where the LM arises from the supero-medial aspect of the distal pulmonary artery, taking an unusual course within the wall of the aorta: ALCAPA with Intramural Aortic Route (ALCAPA-IAR). Both Coronary artery Computed Tomographic Angiography (CCTA) and digital subtraction angiography were used to image the patient prior to surgical intervention. ALCAPA-IAR was confirmed and repaired in the operating room. While this variant has been described in the literature, the appearance on CCTA has not yet been described. Recognizing this variant on preoperative imaging is vitally important as it can affect the surgical approach.